Healthcare pooling for high cost claims

Over the last few years, advances in medicine have brought many life saving drugs—and hope—to people suffering from serious health problems. At the same time, new ways to diagnose illness— sooner— are being developed. So are new treatment guidelines, which help control disease more effectively. The result is that doctors now prescribe drugs sooner than they did in the past, and Canadians are taking more drugs than ever before. While these treatments improve life and sustain a healthy and contributing workforce, some of these drugs are costly. These and other trends are putting pressure on employee benefit plans.

The healthcare pooling solutions that Empire Life has developed will insulate benefit plans from the full impact of high cost claims that are not covered by provincial plans.

Is pooling for you?

If your plan is fully insured

The Canadian Drug Insurance Pooling Corporation (CDIPC) requires that all fully insured drug benefit plans include pooling protection in the form of an Extended Healthcare Policy Protection Plan (EP3), starting in 2013. As not all claims are eligible for pooling in the EP3, Empire Life is providing insured plans with an alternate pooling arrangement called Large Amount Pooling (LAP). LAP works the same as the EP3 but it is not bound by CDIPC standards.

If your plan is ASO (Administrative services only)

The CDIPC guidelines stipulate that ASO plans are not eligible to have high cost claims pooled in an EP3. To ensure that all our customers benefit from pooling protection, we are providing LAP to all ASO customers in addition to our insured customers. As noted above, LAP works the same as the EP3 but it’s administered by Empire Life and is not bound by CDIPC standards.

Whether you have insured benefits or you are ASO, you can rest easy knowing your drug plan is sheltered from high cost claims.

How healthcare pooling works

In a nutshell, pooling protects your plan from high cost healthcare claims. Once the combined claims of an employee— and his or her eligible dependants, if any— go higher than a specified amount (your pooling threshold), the claims are fully pooled. These costs do not get reflected in your Extended Healthcare Benefit (EHB) rate. Instead, you will be charged an annual pooling charge. And because the claim costs are shared across all of our customers participating in the pool, you are insulated from the full impact of any high cost claims.

We are committed to making the whole process transparent and clear, so the details are spelled out in our Healthcare Pooling Administrative Guidelines.

Key features and benefits

The CDIPC has set rules that all healthcare insurance carriers must follow when it comes to healthcare pooling. We’ve gone several steps beyond these basic requirements to ensure that all of our customers can benefit from this cost-effective protection.

Our healthcare pooling features include:

Choice of pooling thresholds, which allows you to manage your benefit plan costs according to your risk tolerance and budget